Shortness of breath – a symptom not always understood ❧ Case Conference March 18, 2014 Andrea Caballero Chief Complaint ❧ ❧ DOE x 1 week HPI – 1st presentation ❧ 54 year-old woman with PMHx of HIV (CD4 count 485; 30.6%), DM2, HTN and CKD stage 3 who presented with DOE. Four days prior to presentation, she experienced an episode of SOB while walking in the Dollar Store. She returned to her car and sat down for a while and her SOB resolved. Dyspnea progressively worsened => exacerbated with exertion and improved with rest. ❧ No CP, diaphoresis, headache, dizziness, N/V ❧ At baseline she could ambulate a little over a block before getting SOB. On presentation she would get SOB after 50ft. ❧ Baseline 3 pillow orthopnea; no PND ❧ Decreased PO intake, but still urinating 5-6 times/day due to the furosemide she takes for pedal edema (at baseline). ❧ No fever, chills, cough or calf pain/redness/swelling. HPI ❧ ❧ Earlier that day: ❧ Pt was seen at diabetes clinic and metformin was discontinued due to increase in Creatinine from baseline of 1-1.4 (GFR 50-59) to 2.6 (GFR<30). ❧ Patient did not complain of any symptoms Past Medical History ❧ ❧ HIV (diagnosed on 3/2013– CD4 391 / 24.3% and on 7/13- 485 / 30.6%). ❧ Hypertension ❧ Diabetes mellitus type 2 (A1C 7.8 on day of admit) ❧ CKD stage 3 ❧ Dyslipidemia ❧ Iron Deficiency Anemia ❧ Vitamin D deficiency ❧ Central Retinal Vein Occlusion with Cystoid Macular Edema Past Surgical History ❧ ❧ Cone biopsy ❧ Hysteroscopy w/ polypectomy Medications ❧ ❧ Lamivudine-Zidovudine ❧ Furosemide 40mg Qday 150-300mg BID ❧ Spironolactone 50mg Qday ❧ Raltegravir 400mg BID ❧ Pravastatin 40mg QHS ❧ Metformin 1000mg BID ❧ Esomeprazole 40mg Qday ❧ Insulin Glargine 42Units BID ❧ Colace 100mg prn ❧ Insulin Aspart 16Units QAC constipation ❧ Amlodipine 10mg Qday ❧ Ferrous Gluconate 240mg ❧ Clonidine 0.2 TID Qday ❧ Labetalol 300mg TID ❧ Loratidine 10mg Qday ❧ Lisinopril 40mg Qday ❧ Timolol 0.5% opth BID Allergies ❧ ❧ NKDA Family History ❧ ❧ DM2 and HTN in several first degree relatives Social History ❧ ❧ Negative for tobacco, alcohol, and illicit drug use ❧ Lives alone and works as a bus driver and hall monitor at a school in the lower 9th ward ❧ 3 heterosexual partners; partner 9 months prior to HIV diagnosis likely source Health Maintenance ❧ ❧ Up to date on influenza vaccine ❧ Up to date on Tdap vaccine ❧ Received 1st dose of Hepatitis B vaccine ❧ No pneumococcal vaccine ❧ Up to date on PAP ❧ Mammogram > 1yr ❧ Colorectal cancer screen - FOBT neg x 3 ROS ❧ ❧ Gen: No weight changes ❧ HEENT: no visual changes/sore throat/rhinorrhea ❧ CV: per HPI ❧ RESP: per HPI ❧ GI: per HPI ❧ Neuro: No numbness ❧ Skin: No new rashes ❧ GU: No complaints Physical Exam ❧ ❧Vitals ❧Triage ❧ BP 111/59 P 107 RR 26 T 96.8 O2 100% on RA ❧ 5’0” 126kg BMI 54 ❧Exam ❧ BP 93/57 P 94 RR 16 T 98.8 O2 98% on RA Physical Exam ❧ ❧ Gen: Alert, appears stated age and cooperative, obese, uncomfortable but in no distress. Could speak in full sentences ❧ Head: Normocephalic, without obvious abnormality, atraumatic ❧ Eyes: Conjunctivae/corneas clear. PERRL, EOM intact. ❧ Throat: Lips, mucosa, and tongue normal; teeth and gums normal ❧ Neck: No adenopathy, no carotid bruit, unable to assess JVD secondary to body habitus, supple, symmetrical, trachea midline ❧ Lungs: Clear to auscultation bilaterally, no w/r/c ❧ Heart: Tachycardic, regular rhythm, S1, S2 normal, no S3/S4/m/r ❧ Abdomen: Obese; bowel sounds normal; soft, non-tender; no organomegaly could be appreciated Physical Exam ❧ ❧ Extremities: Extremities normal, atraumatic; no cyanosis or edema ❧ Pulses: 2+, symmetric radial and DP pulses bilaterally. ❧ Skin: Dry skin, no rashes ❧ Neuro: Awake, alert, and oriented x4. Sensation intact to light touch; biceps, patellar reflexes 2+. Strength is 5/5 bilaterally in the upper and lower extremities. Cerebellar function intact as demonstrated by finger to nose evaluation. CN II-XII: intact Labs Admit ❧ (7-25) (20-25) (13.5-17.5) 135 101 48 204 (10-11) (80-100) 5 17 2.66 (65-99) 10 113.5 (25-28) (1.2) (5-6) 6.8 234 (24-32) (0.5-1.10) (4.5-11) 30.3 17.2 (33-34) (11.5-14.5) AG 19 (40-51) Ca 9.1 Mg 2.1 Phos 3 N 60 L 21 M 16 E 3 TP Alb TB AST ALT ALP 7.4 3.2 1.0 35 29 114 (3.4-5) Labs cont’d ❧ UA: Sg 1.020 RBC 6-10 Trop <0.01 pH 5.0 WBC 3-5 BNP 29 Prot Neg Sq >100 D-dimer 2519 Glu Nml Bact Rare Lactic acid 4.4 (0.3-2.4) Ket 5 Casts Neg CK 460 Blood 25 PT 12.5/NR 1.2/PTT 27 Nitrite Neg ABG on RA 7.25/35/80/94.4% Urobil 1.0 Utox - negative (7.35-7.45)(35-45) Hospital Course ❧ ❧ DOE - negative trop, BNP 29. CXR clear. D-dimer 2519, VQ scan negative. TTE with normal systolic function (EF >55%). ABG 7.25/35/80/15. Believed to be partly 2/2 body habitus. ❧ AGMA - thought to be 2/2 metformin and ART. Both discontinued. Lactic acid 4.4 on admit, 4.3 on discharge. AG improved (15) 138 107 35 204 5.2 18 1.5 ❧ AKI on CKD3 - FeNa 0.25%, no eos. CK 460. Creatinine decreased to 1.5 by discharge with IVF. Thought to be from dehydration and over diuresis. Stopped ACEI, spironolactone and furosemide. Hospital Course cont’d ❧ ❧ HIV - ART stopped. CD4 432 (27.2%) ❧ DM2 - A1C 7.8. Basal insulin decreased to 25 Units BID ❧ Patient was discharged home and followed up with her PCP at HOP 3 days later. HPI – 2nd presentation ❧ ❧ Re-presented to ED 5 days after discharge stating that her DOE was not improved ❧ Since the time of discharge she had also been experiencing lower abdominal pain (unable to point to exact location), present all the time, 10/10. She was not able to keep any food or liquids down, despite feeling hungry. She would vomit whenever she attempted to eat or drink anything. ❧ Non-bloody, non-bilious, usually whatever food/drink she had just consumed. ❧ No alleviating factors. ❧ Denied subjective fevers, chills, night sweats, dysphagia, changes in BM quality/color (last BM morning of presentation), dysuria/hematuria, discharge. Physical Exam ❧ ❧Vitals ❧Triage ❧ BP 136/73 P 98 RR 24 T 97.8 O2 99% on RA ❧ 5’0” 126kg BMI 54 ❧Exam ❧ BP 111/47 P 99 RR 22 T 98.5 O2 100% on RA Physical Exam ❧ ❧ Gen: Alert, appears stated age and cooperative, obese, uncomfortable but in no distress. Could speak in full sentences but appeared tired. ❧ Head: Normocephalic, without obvious abnormality, atraumatic ❧ Eyes: Conjunctivae/corneas clear. PERRL, EOM intact. ❧ Throat: Lips, mucosa, and tongue normal; teeth and gums normal ❧ Neck: No adenopathy, no carotid bruit, unable to assess JVD secondary to body habitus, supple, symmetrical, trachea midline ❧ Lungs: Clear to auscultation bilaterally, no w/r/c ❧ Heart: Tachycardia, regular rhythm, S1,S2 normal, no S3/S4/m/r ❧ Abdomen: Obese, bowel sounds normal; soft, pain with deep palpation and manipulation of RL pannus, no erythema;; no masses, no organomegaly could be appreciated. Physical Exam ❧ ❧ Extremities: Atraumatic, no cyanosis or edema ❧ Pulses: 2+, symmetric radial and DP pulses bilaterally. ❧ Skin: Dry skin, no rashes ❧ GU: No lesions on labia, vaginal canal without erythema, scant white discharge, not foul smelling. Cervix closed, no discharge, purple in color. No tenderness with speculum. Could not perform bimanual 2/2 body habitus. Wet prep - no trich, <50% clue cells ❧ NEURO: Awake, alert, and oriented x4. Sensation intact to light touch. Reflexes are 2+ in biceps, patellar. Strength is 5/5 bilaterally in the upper and lower extremities. Cerebellar function intact to finger to nose. CN II-XII: intact Labs ❧ (7-25) (20-25) (13.5-17.5) 134 103 43 166 (10-11) (80-100) 5.8 12 2.25 (65-99) 10.6 114.6 (4.5-11) (25-28) (1.5) (5-6) 11 311 (24-32) (0.5-1.10) 43.2 18.9 (33-34) (11.5-14.5 ) AG 22 (35-46) Ca 9.5 Mg 2.6 Phos 3.0 N 70 L 10 M 3 E 1 B 1 bands 7 TP Alb TB AST ALT ALP 7.3 3.0 2.0 43 33 264 (3.4-5) (<1.3) (20-120) Labs cont’d ❧ UA: (<0.3) Sg 1.024 RBC 51-99 Beta-OH 1.87 pH 6.5 WBC 6-10 Trop 0.02 Prot 25 Sq >100 BNP 81 (0.3-2.4) Glu Neg Bact Neg Lactic acid 4.9 Ket 15 Casts 6-10 ABG on RA 7.25/27/95/95.8% Blood 250 (7.35-7.45)(35-45) Nitrite Neg Utox - negative Urobili 8.0 Admission ❧ ❧ Patient admitted to LSU Medicine ❧ CXR clear. ❧ ABG 7.25/27/95/11.8. ❧ BNP 80, recent ECHO normal. ❧ AGMA – anion gap 22. Likely from renal function and medications (recently stopped). Lactic acid 4.9. ❧ With leukocytosis and abdominal pain, cultures sent and empirically started on Vancomycin/Piperacillin- Tazobactam/Ciprofloxacin (renally dosed) Admission cont’d ❧ ❧ AKI on CKD3 - Creatinine increased at 2.2 (1.5 on discharge). FeNa 0.18%, no eosinophils. Started IVF. ❧ Elevated AP/Tbili, N/V - lipase 48. RUQ ultrasound was limited by patient’s body habitus, showed hepatomegaly (diameter of 19cm, CBD 2.9mm) Day 2 ❧ ❧ Blood Pressures low/nml with Tachycardia (90s-100s), oxygen saturations wnl ❧ DOE - unchanged ❧ Nausea and vomiting with minimal improvement. ❧ Pannus still TTP. ❧ Alk Phos and Tbili continued to increase. ❧ On broad spectrum abx, all cultures NGTD.